ECF CHOICES Claim Reference Guide. June 2017

Transcription

1 Cameron hill circle hattanooga.tn bluecare.bcbst.com ECF CHOICES Claim Reference Guide June 2017 BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association

2 Table of Contents I. Contact Information a. Phone Numbers b. Quick Links II. Submission Methods a. Electronic Visit Verification b. Web Portal III. IV. Billing Guidelines and Benefit Limits Claim Explanation/Denial Codes V. Timely Filing VI. VII. Rejected Claims Appeals 2

3 I. Contact Information ECF CHOICES Provider Service ebusiness or Sandata Technologies Provider Inquiry Specialists for EVV missed or late visits Useful Links BlueCross BlueShield of Tennessee Website BlueAlert Newsletters BlueCare Provider Administration Manual Administration-Manual.html BlueCare Tennessee Website CHOICES/ECF CHOICES Newsletters Administration-Manual-and-Newsletters.html ebusiness Tools and Resources II. Claim Submission Methods Electronic Visit Verification System (EVV) The Electronic Visit Verification (EVV) System is an electronic system provider staff and consumer-directed workers can use to record visits with members. Users simply check in and check out at the beginning and end of each period of service delivered. The EVV system helps ensure the member is receiving Home and Community Based Services (HCBS) as outlined in his or her Plan of Care. The system provides a record to show the services were provided, which is closely monitored by the BlueCare Tennessee care coordination area. All EVV claims are sent to BlueCare Tennessee through a secure File Transfer Protocol (FTP) connection facilitated by Sandata Technologies*. The following services must be filed through the EVV System. EVV Personal Assistance Respite Supportive Home Care * Sandata Technologies is an independent company that does not provide BlueCare Tennessee branded products and services. 3

4 BlueAccess SM ECF / BlueCare Tennessee uses an online application for Employment and Community First (ECF) providers to submit claims. ECF providers can use BlueAccess to check the status of their claims and view remittance advice statements. The following services may be submitted through BlueAccess. Exploration Supported Employment Benefits Counseling Transition from Group to Individual Employment Discovery Integrated Employment Path Situational Observation & Assessment Community Integration Support Services Job Development Plan and Start-Up Independent Living Skills Training Self-Employment Plan and Start-Up Community Living Supports Job Coaching Community Living Supports Family Model Co-Worker Supports Assistive Technology, Adaptive Equipment and Supplies Career Advancement Minor Home Modifications Individual Education and Training Peer-to-Peer Support Specialized Consultation and Training Family Caregiver Stipend Community Support Family Caregiver Education and Training Conservatorship Health Insurance Counseling/Forms Assistance Please contact ebusiness Solutions at (423) or with questions. III. Billing Guidelines and Benefit Limits The following items are required on all ECF CHOICES Home and Community Based (HCBS) claims. Type of Bill is 089X. Type of Admission (FL14) is required. This code indicates the priority of this admission. Point of Origin for Admission or Visit (FL15) is required. Patient Status (FL17) must be 01 on all HCBS claims. Occurrence Code 55 and the corresponding Date of Death are required on all claims submitted with Discharge Status 20, 40, 41 or 42. All Dates of Service must be within the same calendar month. Line Item and Statement Dates must match. The Statement From date must be the earliest line item date and the Statement To date must be the latest line item date. Attending Physician (FL76, 1 & 2) is required on all ECF CHOICES claims as follows: o Consumer Direction (CD): The worker s assigned CD number will be submitted as the Attending Provider. The ID must be within the range of CD00001 CD o Attending Providers with an NPI: The provider s NPI will be submitted as the Attending Provider. The NPI must be valid and recognized by BlueCross BlueShield of Tennessee. o Atypical Attending Providers without an NPI: The provider s Medicaid ID number will be submitted as the Attending Provider. The Medicaid ID number must be valid and recognized by BlueCross. 4

5 Billing Codes All services must be approved in the Person-Centered Support Plan prior to reimbursement. The appropriate modifier(s) will be provided in the authorization notification. Revenue Code Procedure Code Modifier Code Services and Descriptions Submission Method 969 T2025 UA Exploration Individual 969 T2025 U2 Discovery Individual 969 T2025 U4 Job Development Plan 969 T2025 UAU1 UAU2 UAU3 UBU4 UBU5 UBU6 U4U1 U4U2 U4U3 Job Development Start Up 969 T2025 U3 Situational Observation and Assessment Individual 969 T2025 U5 Self-Employment Plan 969 T2025 USUAU1 USUAU2 USUAU3 USUBU1 USUBU2 USUBU3 USU4U1 USU4U2 USU4U3 Self-Employment Start Up 969 T2019 U1UBUP Co-Worker Supports 969 T2025 U8 U9 Career Advancement 969 T2019 U2 969 T2019 U3 969 T2025 U3UB Supported Employment (Small Group - Max of 2 persons) Supported Employment (Small Group - Max of 3 persons) Transition from small group to individual employment - This is an Incentive Payment, not a 'service'. 969 T2015 U1 U2 Integrated Employment Path Services (Time-Limited Prevocational Training) T2021 None or U1 U1UA Community Integration Support Services T2021 and T2021 with modifiers to be used based on the services provided T U1 U T2028 plus modifiers to be used for cost of registration, materials and supplies for participation in classes, conferences, or club/association dues. U1 modifier signifies children under age 21. U2 modifier signifies 5

6 adults Allowable costs are maximums. 969 T2021 U2 Independent Living Skills Training 969 T2025 UB U1UB U2UB Benefits Counseling 969 T1019 UA Personal Assistance EVV* 969 T2003 Community Transportation (Consumer Directed) 590 T2029 U4 Assistive Technology, Adaptive Equipment and Supplies 590 S5165 Minor Home Modifications 969 T2012 Individual Education and Training 969 T2013 Peer-to-Peer Support and Navigation for Person- Centered Planning, Self-Direction, Integrated Employment/Self-Employment and Independent Community Living 942 G0159 G0160 G0161 G0164 S9470 H2015 None or U1 Specialized Consultation and Training G0159 = OT; G0160 = PT; G0161 = SLP; G0164 = RN; S9470 = Nutritionist; H2015 = Behavioral Supports These services are consultative in nature and not provision of direct services. 570 T1019 None or U2 Supportive Home Care EVV* 570 T1020 U1 or U2 Family Caregiver Stipend in lieu of Supportive Home Care 969 T2025 SZ Family to Family Support 969 T2025 U5UA Community Support Development, Organization and Navigation 969 T2012 UA Family Caregiver Education and Training 969 T2025 U1SE U2SE U3SE Conservatorship and Alternatives to Conservatorship Counseling and Assistance 969 T2025 SE Health Insurance Counseling/Forms Assistance 960 T2033 U1UA U3UA U4UA U5UA U6UA U7UA Community Living Supports 960 T2016 U1UA U2UA U3UA U4UA U5UA U6UA Community Living Supports Family Model 660 S9125 None, UA In-Home Respite, per day EVV 6

7 or UB 660 S5150 None or U1-U5 UA UA U1 UA U2 UA U3 UA U4 UA U5 In-Home Respite, per 15 minutes EVV* *Consumer Directed services will not be submitted via EVV. Per Diem Services The reimbursement for per diem services is limited to once per day. To ensure proper reimbursement, each date of service should be billed on a separate line on the claim unless the service was provided on consecutive days. This billing guideline applies to the following services: Service Description Respite Family Caregiver Stipend Community Transportation Family or Individual Education and Training Community Living Supports Family Model Community Living Supports Service Code S9125 T1020 T2002 T2012 T2016 T2033 Examples: Member received services every day 1/1/17-1/15/17. The claim should be billed with one line item for dates of service 1/1/17-1/15/17 with 15 units of service. Member received services 2/1/17, 2/5/17, and 2/10/17. The claim should be billed with one line for each date of service with 1 unit of service, for a total of three lines. Member received services 3/1/17, 3/2/17, and 3/5/17. The claim should be billed with two lines. One line for dates of service 3/1/17-3/2/17 with 2 service units and one line for 3/5/17 with 1 service unit. 7

8 Job Coaching Job Coaching services will be submitted with Revenue Code 969. The following chart shows the HCPCS and Modifiers. All services must be approved in the Person-Centered Support Plan prior to reimbursement. The appropriate modifier(s) will be provided in the authorization notification. Job Coaching - Individual Wage Employment Months on job Tier A Tier B Tier C hours hours hours 1-6 months T2019 UA T2019 UB T2019 XU % T2019 UA U % T2019 UB U % T2019 XU U months 80-89% T2019 UA U % T2019 UB U % T2019 XU U2 < 80% T2019 UA U3 < 60% T2019 UB U3 < 40% T2019 XU U % T2019 UA U % T2019 UB U % T2019 XU U months 60-74% T2019 UA U % T2019 UB U % T2019 XU U5 < 60% T2019 UA U6 < 40% T2019 UB U6 < 30% T2019 XU U % T2019 UA U % T2019 UB U % T2019 XU U months 40-64% T2019 UA U % T2019 UB U % T2019 XU U8 < 40% T2019 UA U9 < 30% T2019 UB U9 < 20% T2019 XU U months T2019 TS U1 T2019 TS U2 T2019 TS U3 Stabilization & Monitoring ~ 1/wk T2025 TS U1 ~ 1/wk T2025 TS ~ 1/wk T2025 TS U3 Job Coaching - Self- Employment Months on job hours Tier A hours Tier B hours Tier C 1-6 months T2019 UA US T2019 UB US T2019 XU US % T2019 UA US U % T2019 UB US U % T2019 XU US U months 80-89% T2019 UA US U % T2019 UB US U % T2019 XU US U2 < 80% T2019 UA US U3 < 60% T2019 UB US U3 < 40% T2019 XU US U % T2019 UA US U % T2019 UB US U % T2019 XU US U months 60-74% T2019 UA US U % T2019 UB US U % T2019 XU US U5 < 60% T2019 UA US U6 < 40% T2019 UB US U6 < 30% T2019 XU US U % T2019 UA US U % T2019 UB US U % T2019 XU US U months 40-64% T2019 UA US U % T2019 UB US U % T2019 XU US U8 < 40% T2019 UA US U9 < 30% T2019 UB US U9 < 20% T2019 XU US U months T2019 U1 US T2019 U2 US T2019 U3 US Stabilization & Monitoring ~ 1/wk T2025 TS US U1 ~ 1/wk T2025 TS US U2 ~ 1/wk T2025 TS US U3 8

9 IV. Claim Explanation/Denial Codes Additional information about common Explanation Codes you may see on your Remittance Advice. Please contact BlueCare Provider Service at should you have any questions about claims processed with these or any other Explanation Codes. Explanation Statement on Remittance Codes (EX) Advice 073 or REJ Benefits for this service are excluded under this member's plan. AUT PS2 Benefits cannot be provided for this service because the required authorization is not on file. The maximum number of services payable under this member's coverage has been provided. Additional information about why code was used This EX Code is generated when the member s ECF CHOICES coverage has ended but an authorization is on file for the service billed. Please contact Provider Service for assistance with claims receiving this denial. This EX Code indicates a matching authorization was not found at the time of processing. This EX Code is generated when the benefit limit for the service billed has been met or exceeded. TF1 The claim for these services was received after the time limit specified in the provider's agreement. This EX Code is generated when a claim is not received within timely filing limits. Please refer to the Timely Filing section of this document for more detailed information about timely filing limits. TR0 UM1 UM2 Benefits cannot be provided because there was no authorization and/or referral for this service. The number of services provided exceeds the number approved in the Utilization Management authorization. These services were limited by a Utilization Management authorization. This EX Code indicates a matching authorization was not found at the time of processing. This EX Code is generated when the billed units exceed the authorized units. This EX Code is generated when the billed units exceed the authorized units. WF0 Possible Corrected Bill The explanation is generated when a claim is received that overlaps a previously-submitted claim and appears to be a corrected claim. 9

10 WK2 / WK3 Corrected Bill was received after the time limit for submission. This EX Code indicates the Corrected Claim was not submitted within timely filing limits. Please refer to the Timely Filing section of this document for more detailed information about timely filing limits. WM5 WT3 X87 Statement from/thru dates must correspond service line dates of service before benefits can be provided. Benefits cannot be provided since the dates of service must equal the number of units billed. The provider may file a corrected bill. The provider must submit a correct Type of Bill and revenue code combination before benefits can be provided. This EX Code is generated when the claim line dates of service do not match the claims statement dates. A corrected claim must be submitted. This EX Code is generated when the units billed do not correspond with the dates of service billed. A corrected claim must be submitted. This EX Code is generated when an incorrect type of bill has been submitted or when an incorrect Revenue Code/HCPCS Code combination has been submitted. A corrected bill must be submitted. V. Timely Filing Limits Claims must be submitted within 120 days from the date of service or within 60 days from the date of the original BlueCare Tennessee rejection notice, whichever is later. This denial can be reviewed per the Provider s request, with acceptable documentation, such as a copy of a 277 Error Report. The member cannot be billed when a claim has received a timely filing denial. ECF CHOICES Retro Eligibility Timely filing for ECF CHOICES claims is 120 days from the date of service or the date the Managed Care Organization (MCO) is notified of the ECFCHOICES coverage. If the date the MCO is notified of the ECF CHOICES coverage is 120 days from the date of service, the claim should not deny for timely filing. Corrected Claim Timely Filing Timely filing for corrected bills is 120 days from the remittance date of a claim. If there are multiple submissions of a corrected bill, the first submission of the corrected bill will be used for adjustment. VI. Rejected Claims If you have filed a claim that BlueCare Tennessee rejects, you may wish to make corrections and resubmit. If the original claim was not accepted, you do not have to submit it as a corrected bill. As a reminder, rejected claims must be resubmitted within 120 days of the date of service or 10

11 within 60 days from the date of the original BlueCare Tennessee rejection notice, whichever is later. If you have questions concerning specific information on how to file an electronic claim, please visit our website at bluecare.bcbst.com or contact ebusiness at VII. Appeals Reconsiderations and Appeals Information regarding the Reconsideration and Appeals Process, along with all needed forms can be found at Independent Review In addition to the Provider Dispute Resolution Process, you may file a request with the Commissioner of Commerce and Insurance for an independent review. Sample copies of the Request to Commissioner of Commerce & Insurance for Independent Review of Disputed TennCare Claim form, instructions for completing the form, and frequently asked questions developed by the State of Tennessee Department of Commerce and Insurance can be found in Section XII of the BlueCare Tennessee Provider Administration Manual. A current copy of the form can be obtained on the state s Web site at or by calling the State of Tennessee at (615)